At Lankino Medical Center, Francis Sutter, a cardiothoracic surgeon from Philadelphia, sits in a dark corner of the operating room, his head sunken into what looks like a large virtual reality helmet. His hands are away from the chest of the operated patient; He uses two joysticks to move the robot, which makes tiny incisions near the beating heart.
Robotic operations
It is true that the settings are similar to video games, but there is no electronic game that involves this amount of risk. “One wrong move with the robot arm makes a hole in the heart,” says Sutter.
Here we are talking about replacing a new artery with a blocked one; that is, what is known as “surgery to open a bypass (bypass) of the coronary artery”; The most common heart surgery in the United States. But the method Sutter uses isn’t popular. Data from the Society of Thoracic Surgeons indicates that robots have been responsible for just 1 percent of these surgeries over the past five years.
In 2021, only about 1,800 robotic surgeries were performed; 200 of them are at Lanquino Medical Center, where Sutter heads the department of cardiac surgery.
Robots have become commonplace in some cardiac procedures, but many surgeons are skeptical that robotic assistance is an improvement in the process.
Sutter relays this to patients who qualify for this surgery; Because it protects them from open-heart surgery, which includes breaking the breastbone and stopping the heart from beating, in addition to a scar on the skin ranging between 6 and 8 inches. He adds that his patients go home with small incisions, the largest of which is no more than two inches (5 cm).
Critics of these robotic approaches, including some prominent Philadelphia surgeons, say that many patients who qualify for this surgery need to open more than one pathway, which is often not possible with Sutter’s technique, in addition to the fact that the robot may raise the cost of surgery.
Sutter hears a lot of criticism, but remains hopeful his research will help encourage more surgeons to take advantage of the robotic procedure he’s been performing for more than two decades.
An educational and experimental path
In 1986, Sutter began performing coronary artery bypass surgery using the standard approach, which he considered aggressive and risky. Which is why he took immediate interest when he heard that some surgeons around the world had begun using robots for this procedure in the late 1990s.
He saw a tool that allowed surgery on a beating heart and spared doctors that terrifying moment when they pray for the heart to start working again. Sutter believed that robotic surgery might help reduce recovery time and allow him to operate on patients who would not tolerate conventional surgery.
The surgeon began performing the procedure 18 years ago, and to this day he is still amazed when he sees his patients sitting up in bed after only a few hours.
specialized procedure
Sutter uses a robot to correct the blockage in the largest artery that supplies blood to the heart muscle, in a two-part surgery that takes about 4 hours.
First, the surgeon uses a robot to “harvest” the northern internal mammary artery. The practical option to replace the damaged artery in many of these surgeries. The robot puts on a sterile glove and sutures the “prosthetic” artery in the heart, allowing blood flow to bypass the blockage. This step requires the largest incision during the surgery, which is no more than two inches long.
In the past, Sutter could perform the entire procedure using a robot, but the company that made the latter has stopped making the vital surgical instrument due to low demand.
Sutter said he surgically corrects only one artery in 80 percent of his patients. And because people often suffer from more blockages in the vessels; Many of his patients have a stent, a spring-like device implanted through a catheter, into other vessels. The surgeon prefers this procedure over opening the chest and performs several lateral opening procedures in cases that allow it.
Medical controversy over the employment of a surgical robot
Hospitals often chase the most advanced treatments, even when the cost is not fully supported by research. But Philadelphia heart surgeons don’t follow Souter’s robotic method.
“There are a lot of skilled cardiac surgeons, and there’s a reason they don’t use this method,” says Rohinton Morris, chief of the department of cardiac surgery at Jefferson University Hospital. He adds that the concern about using a heart-lung machine is outdated, and that about 90 percent of bypass surgeries at Jefferson are performed on a stopped heart without the use of a robot.
Temple University Hospital also does not use a robot to perform this procedure, according to Yoshia Toyoda, head of the Department of Cardiovascular Surgery. Because what he fears most is the limitations of robotic technology in terms of the number of arteries that the surgeon can correct. Toyoda usually repairs 4 arteries in one operation, and sometimes the number reaches 8.
“Better incision in the skin or a complete revascularization,” Toyoda asks. Which is better? I think the patient will benefit from the second.”
The University of Pennsylvania Hospital and University-affiliated Presbyterian Medical Center use the robot in 10 percent of the 550 coronary bypass surgeries performed annually at the two facilities, a university spokesperson revealed.
Surgeons are also concerned about the cost, with the robot alone costing $2 million, as well as the cost of training surgeons to become Sutter’s skill.
T. Sloan-Gay has headed the Robotic Surgery Team at the Society of Thoracic Surgeons for years. He specializes in mitral valve repair and uses the robotic method in 98 percent of cases. But when he does coronary artery bypass surgery, he does it the traditional way. Gaye counted that the procedure Sutter uses “is a kind reserved for the elite of the elite who dedicate themselves to it.”
But Gaye, who trained and worked in Philadelphia, is very optimistic about the future of robotic heart surgery, and believes that the improvement of this technology will turn it into a standard due to the high demand from people for it. He points out that “quick recovery and minor surgical intervention are important for patients.”
Promising data
Sutter realizes that the current trajectory has a negative impact on robotic bypasses. But he believes that surgery should be the choice of the beneficiary patient.
At the most recent “Society of Thoracic Surgeons” conference, one of Sutter’s students, surgeon Alexandre Ducolari, presented a preliminary analysis of about 2,400 robotic bypass surgeries performed at the Lanquino Center, and the results were promising.
Other studies outside of Lankino also found the robotic procedure to be safe and suggested positive outcomes. However, to date, there is no study using a randomized controlled trial, considered the gold standard in medical research, to evaluate robotic technology against conventional surgery.
For now, Sutter is convinced he’s in the right place, in his operating room, looking at a 3D heart monitor 10 times larger, while a robotic arm performs the surgery a few feet away.
* “The Philadelphia Inquirer”
Tribune Media services.
